1164019162 NPI number — GREAT FALLS GERIATRIC MEDICINE, LLC

Table of content: (NPI 1164019162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164019162 NPI number — GREAT FALLS GERIATRIC MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT FALLS GERIATRIC MEDICINE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164019162
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 440
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREAT FALLS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22066-0440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10017 PARK ROYAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREAT FALLS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22066-1847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-947-7377
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/23/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
REYBURN
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
703-947-7377

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0101265405 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com